Ageing Int (2016) 41:89–98
DOI 10.1007/s12126-015-9227-1
Trade-off Between Quality, Price, and Profit Orientation
in Germany’s Nursing Homes
Max Geraedts 1 & Charlene Harrington 2 &
Daniel Schumacher 1 & Rike Kraska 1
Published online: 17 October 2015
# The Author(s) 2015. This article is published with open access at Springerlink.com
Abstract International data suggest that for-profit nursing homes tend to provide lower
quality than not-for-profit nursing homes. In Germany, the relationships between profit
orientation, price and quality of nursing homes have not been investigated. We
performed an observational study using secondary data from statutory quality audits
of all nursing homes in Germany. The relationships were analyzed bivariately via
Mann–Whitney U-Test and Kruskal-Wallis Test respectively, followed by a multivariate variance analysis which also covered the interaction effect between quality, price
and type of ownership. 41 % of 10,168 German nursing homes were for-profit charging
on average about 10 % less than not-for-profit homes. In five out of six quality
categories under study, for-profit nursing homes provided lower quality than not-forprofit homes. Quality of care in all quality categories improved with increasing prices
per day. However, for four out of six quality categories examined, the quality difference
between for-profit and non-profit nursing homes existed independent of the price
charged. When selecting a nursing home it is therefore advisable to consider the profit
orientation of the institution. German legislation should require that statutory public
quality reports contain details on the profit orientation of nursing homes.
Keywords Nursing homes . Germany . Ownership . Profit orientation . Quality of care
* Max Geraedts
[email protected]
1
Institute for Health Systems Research, School of Medicine, Faculty of Health, Witten/Herdecke
University, Alfred-Herrhausen-Strasse 50, 58448 Witten, Germany
2
Department of Social and Behavioral Sciences, University of California, San Francisco, 3333
California St., Suite 410, San Francisco, CA 94143, USA
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Ageing Int (2016) 41:89–98
Introduction
Germany, like other industrialised nations, is faced with a steadily increasing risk of
need for long-term-care services as a consequence of demographic change. A growing
number of people in old age depend on support for activities of daily living (ADL).
Most citizens prefer to receive care in their own homes, but towards the end of life
many cannot manage without in-patient care in a nursing facility. A growing number of
citizens must address the question as to which nursing home is suitable for their
individual requirements.
In Germany an obligatory audit for all nursing homes that was introduced in 2009
facilitates this choice; the health insurance funds’ medical service departments evaluate
institutional care facilities at least once per year on site, based on a statutory checklist of
82 criteria. Nursing homes are required by law to display audit results on the premises,
and statutory nursing insurance funds publish all results via internet.
Long-term-care (LTC) insurance was introduced in Germany in 1995 as a
mandatory element of all statutory and private health insurance schemes (Geraedts
et al. 2000), so that the entire population is now protected against long-term-care
costs. Concurrent with the introduction of LTC insurance, the government started
to promote the building and expansion of outpatient and inpatient long-term-care
facilities. In this context state funding was available to public non-profit or
charitable providers of long-term-care as well as private for-profit providers. As
a consequence, the share of for-profit providers of nursing care among outpatient
nursing services in Germany increased from 51 to 64 %, and among nursing
homes from 35 to 41 % between 1999 and 2013 (Statistisches Bundesamt 2001,
2014).
In a market they share with non-profit providers, for-profit providers of nursing
care have to contend with the basic problem of higher capital costs, which may
partially be offset by more efficient management, higher prices or diminishing
service quality levels. It is generally difficult for users to assess service quality in
the case of experience or credence goods such as nursing services. This is why
for-profit providers might be induced to deliberately compromise quality in favour
of profit maximisation in this sector (Hansmann 1980). Moreover, the most
efficient strategy appears to be cost leadership, since other basic competitive
strategies such as differentiation and niche strategies are not very promising in a
market shared with not-for-profit service providers (Porter 1980). International
literature on the correlation between profit orientation of nursing homes and the
quality of services provided supports the evidence of these theoretical reflections
for the most part. In a meta-analysis, Comondore et al. (2009) concluded that nonprofit nursing homes generally provide better care compared to for-profit nursing
homes. More recent studies confirm the theoretically expected behaviour on the
part of for-profit nursing care providers (Harrington et al. 2012, Harrington et al.
2015). Based on the convincing data available, the US Center for Medicare
Advocacy advises consumers to consider profit orientation in the choice of a
nursing home, and to select a not-for-profit nursing care facility (Medicare Advocacy 2015).
In view of the above, this study aimed to explore the correlation between profit
orientation of German nursing homes, their prices and the quality of care provided.
Ageing Int (2016) 41:89–98
91
Methods
The study was designed as a cross-sectional study based on secondary data. Data
sources, operationalisation of variables and analytical procedures are described in the
following.
Nursing Homes The study was based on the most up-to-date assessments of all
German nursing homes in the years 2011 and 2012 respectively from the statutory
quality audits performed by the health insurers’ medical service departments. Data were
provided by Germany’s largest nursing care insurer, the national sickness fund association AOK (Allgemeine OrtsKrankenkasse), and cover a total of N=10,471 nursing
homes offering full inpatient care. Excluded from these data were homes specializing in
vigil coma patients (N=36), those with no identifiable type of ownership (N=43),
homes with incomplete quality data by more than 50 % (N=2), or with no data on
monthly charges for nursing care (N=222). The number of nursing homes remaining
for the analysis was N=10,168.
Profit Orientation Data on the type of ownership were available for each nursing
home under consideration. A distinction was made between private for-profit institutions and public not-for profit and charitable facilities. Because only 5 % of all German
nursing homes have public ownership, they were combined with charitable homes in
the not-for-profit category for the analysis.
Prices Available cost details for each facility cover daily costs for nursing care, room
and board. Investment costs which nursing homes charge to each home resident
proportionally and on a small scale are not included in the data and therefore do not
enter price calculations for each care facility. Moreover, prices per resident depend on
the extent of care required. Residents are assigned to one of three care levels; the
national distribution of care levels in nursing homes is as follows: care level 1 (lowest) 38.12 %, care level 2 (medium) – 40.29 %, care level 3 (highest) – 20.45 %. The
percentage per nursing home of care recipients assigned to care levels 1 to 3 was not
given, so that an equal distribution was assumed, and the daily price per nursing home
was calculated as weighted mean of the national distribution.
Average prices charged by nursing homes differ greatly between the 16 federal states
in Germany. This is why 5 price categories per federal state were set up with
approximately equal numbers of nursing homes for the calculation of correlations
between prices and quality of service. As a next step all nursing homes in each of
the five price categories were summarized across the nation, and the price was used for
analysis as a categorical variable.
Quality of Care To assess the quality of care provided in nursing homes the authors
used evaluations from the health insurers’ medical service departments collected in
unannounced audits in 2011/2012. Audits are based on a checklist of 82 criteria (GKVSpitzenverband 2008). Eighteen criteria relate to satisfaction surveys among home
residents; 38 criteria are determined from a sample of 5–15 residents, depending on
the size of the facility; the remaining criteria are assessed per facility. In case of
resident-related criteria, the values for individual residents are summed up to form a
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Ageing Int (2016) 41:89–98
final value per criterion on a scale from 1 to 5. Facility-related criteria are dichotomous,
i.e., registered as either existent or non-existent.
For the purposes of this study, criteria were assigned in terms of content to the
following categories: facility structure (4 criteria, e.g., Bsecured recreational areas
outside^, Bfood and drinks provided in a pleasant environment^), nursing processes
(23 criteria, e.g., Brequired pressure sore prophylaxis is implemented^, Bsystematic pain
assessments conducted^, Bbiography of residents suffering dementia taken into account
and being considered when planning daily activities^), support procedures (16 criteria,
e.g., Bcontact with relatives ensured^, Bassistance or information provided to familiarize
new residents with the nursing facility^), documentation of nursing services (7 criteria,
e.g., Bindividual risk of falling registered^, Bindividual risks and resources of residents
with incontinence or a bladder catheter assessed^), patient outcomes (2 criteria,
Bnutritional status appropriate^, Bsupply of fluids appropriate^) and quality management (5 criteria, e.g., Bwritten instructions available on how to proceed in
emergencies^, Bnursing facility has a system for managing complaints^). Five criteria
were not included in the analysis since over 50 % of pertinent data were not available.
Inclusion of two further criteria was not possible since the underlying scale did not
permit assignment to suitable content categories. Criteria related to surveyed resident
satisfaction were not used either, since these surveys were performed on the basis of a
non-validated interview tool and with an insufficient case number and sample size in
most cases (Hasseler et al. 2010).
Statistics The relationships between profit orientation and prices charged by nursing
homes on the one hand, and quality of care on the other were first determined
bivariately via Mann–Whitney U-Test and Kruskal-Wallis Test respectively, followed
by a multivariate variance analysis which also covered the interaction effect between
price and type of ownership. Additionally, post hoc tests with Bonferroni-Holm
correction for multiple testing were performed to discover the trend of correlations
between variables in detail. The statistics software SPSS version 22 was used for all
descriptive and analytical evaluations.
Results
Table 1 shows the absolute and relative frequency of for-profit and non-profit nursing
homes in Germany and average daily prices for long-term-care services, room and
board. Daily rates charged by the 40 % for-profit homes undercut those charged by
non-profit facilities by an average of € 9.17, i.e., more than 10 %.
Table 2 lists the average prices charged per day by nursing homes in the five price
categories. The large spans result from the pooling of nursing homes from different
federal states. The two quintiles 1 and 2 with lowest costs comprise 69 % of for-profit
homes but only about 20 % of non-profit facilities.
Table 3 illustrates the bivariate correlation between profit orientation of nursing
homes and the quality of care provided. With the exception of the category Bpatient
outcomes^ with only two single criteria, the Mann–Whitney U-Test reveals highly
significant differences in all other quality categories: non-profit nursing homes consistently provide better quality of care compared to for-profit facilities.
Ageing Int (2016) 41:89–98
93
Table 1 Frequency and price per day of for-profit and non-profit nursing homes in Germany
Frequency
Average price per day
For-Profit Nursing Homes
Non-Profit Nursing Homes
Total
N
%
N
%
4179
41.1
5989
58.9
10,168
Mean
SD*
Mean
SD
Min-Max#
71.59 €
9.43 €
80.76 €
13.09 €
35–549 €
*SD standard deviation, Min-Max# minimum – maximum price per day
Table 4 shows the bivariate correlation between the five price quintiles and quality
categories. The effect that the service quality in German nursing homes increases with
increasing prices applies to all categories.
Table 5 shows the results of the multi-variate variance analysis. The figure below
additionally illustrates correlations between prices charged by nursing homes, profit
orientation and the six quality categories examined (see figure). Irrespective of profit
orientation, the quality of care in all quality categories improves with increasing prices
per day, the same as in the bivariate analysis. However, profit orientation cannot be
considered as independent of the price in all quality categories. In the categories of
nursing processes, support services, quality management and structures, for-profit
homes perform worse than non-profit institutions, independent of the price charged.
No correlations were found, however, between documentation quality and outcomes on
the one hand and profit orientation of the facilities on the other if the price charged by
the nursing homes is taken into consideration (see Table 5).
Significant interactions between price and type of ownership were found for the
criteria support services, quality management and structures. The three graphs on the
right side of the figure below illustrate that for-profit nursing homes effect stronger
quality improvement between the 1st and 2nd quintiles compared to non-profit homes
(see figure). But for-profit homes achieve a higher quality level than non-profit homes
in only one quintile for these categories.
Across all six quality categories, the level of quality in for-profit nursing homes
is lower than in non-profit homes in 23 out of 30 comparable price quintiles.
Additional post hoc tests with Bonferroni-Holm correction confirm the graphic
impression that there are significant differences in relation to profit orientation
Table 2 Average price per day and number of for-profit and non-profit nursing homes per quintile
Mean €
Median €
Min €
Max €
Quintile 1
67.59
67.79
35.17
Quintile 2
73.28
75.42
58.56
Quintile 3
76.68
78.91
Quintile 4
80.16
81.80
Quintile 5
87.19
Total
76.98
N
N for-profit
N non-profit
82.01
2029
1664
365
86.06
2033
1216
817
60.46
89.48
2033
738
1295
61.89
93.67
2033
362
1671
87.67
65.63
549.06
2040
199
1841
78.32
35.17
549.06
10,168
4179
5989
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Ageing Int (2016) 41:89–98
Table 3 Relationship between profit orientation and quality of care in nursing homes in Germany (Mann–
Whitney U-Test)
Quality category (No of criteria)
For-profit
Non-profit
p-value
4.29a
4.40a
0.000
Documentation (7)
a
4.49
4.58a
0.000
Outcomes (2)
4.93a
4.94a
0.141
b
b
Nursing processes (23)
Support services (16)
97.75
98.95
0.000
Quality management (5)
93.20b
96.26b
0.000
Structures (4)
98.35b
99.11b
0.000
a
average value of all nursing homes on a scale from 1=worst to 5=best
b
average value of all nursing homes on a scale from 0 %=worst to 100 %=best
mainly in the lower price quintiles, whereas the upper price quintile does no longer
reveal any statistically significant differences. It also appears that a good part of
significant improvement happens up to the third price quintile across all quality
categories, and the area beyond shows only consistently significant quality improvement for nursing processes.
Based on a summary of results shown in Tables 3, 4 and 5 and the figure it must be
acknowledged that all identified differences are at a low level and that nursing homes in
general have received very good ratings. Therefore the multivariate model only explains approximately 3 % in the variance of quality differences between for-profit and
non-profit nursing homes, and between nursing homes of different price quintiles
Fig. 1.
Discussion
All in all, for-profit nursing homes in Germany offer a lower service quality compared
to non-profit nursing homes. One explanation for the differences is that for-profit
homes charge lower prices on average and that the quality of nursing services is related
Table 4 Relationship between price per day quintiles and quality of care in nursing homes in Germany
(Kruskal-Wallis Test)
Quality category (No of criteria)
Nursing processes (23)
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
p-value
4.23a
4.30a
4.36a
4.41a
4.47a
0.000
a
a
a
a
Documentation (7)
4.43
4.50
4.55
4.58
4.64a
0.000
Outcomes (2)
4.92a
4.93a
4.94a
4.94a
4.95a
0.009
Support services (16)
97.19b
98.40b
98.79b
98.84b
99.08b
0.000
Quality management (5)
91.82b
94.90b
95.38b
96.02b
96.90b
0.000
Structures (4)
97.86b
98.82b
98.93b
99.07b
99.29b
0.000
a
average value of all nursing homes on a scale from 1=worst to 5=best
b
average value of all nursing homes on a scale from 0 %=worst to 100 %=best
Ageing Int (2016) 41:89–98
95
Table 5 P-values and variance explained of the multivariate relationship between price per day quintiles,
profit orientation and quality of care and their interactions in nursing homes in Germany
Quality category (No of criteria)
Price per day*profit
orientation
R2
Price per day
Profit orientation
Nursing processes (23)
0.000
0.028
0.199
0.022
Documentation (7)
0.000
0.419
0.571
0.018
Outcomes (2)
0.001
0.373
0.894
0.003
Support services (16)
0.000
0.000
0.013
0.026
Quality management (5)
0.000
0.000
0.000
0.028
Structures (4)
0.005
0.004
0.011
0.009
99.5
4.5
Nursing Processes
4.4
4.3
non-profit
for-profit
4.2
4.1
mean value (100% = best)
mean value (1 = worst to 5 = best)
to the price to a highly significant degree. However, for four out of six quality
categories examined, the quality difference between for-profit and non-profit nursing
homes exists independent of the price charged. Therefore German for-profit nursing
98.5
98
2
3
4
non-profit
97.5
for-profit
97
96.5
1
Structures
99
5
1
2
99.5
Outcomes
4.95
mean value (100% = best)
mean value (1 = worst to 5 = best)
4.96
4.94
4.93
4.92
non-profit
4.91
for-profit
4.9
2
3
98.5
98
97.5
97
4
non-profit
96.5
for-profit
96
5
1
mean value (100% = best)
mean value (1 = worst to 5 = best)
Documentaon
4.6
4.55
4.5
non-profit
for-profit
4.45
4.4
4.35
4.3
1
2
2
3
4
5
price per day quinles
98
4.7
5
Support Services
price per day quinles
4.65
4
99
95.5
1
3
price per day quinles
price per day quinles
3
price per day quinles
4
5
Quality Management
96
94
92
non-profit
for-profit
90
88
86
1
2
3
4
5
price per day quinles
Fig. 1 Quality of care in six categories in relation to price per day and profit orientation of nursing homes in
Germany (N=10,168) (note that Y-axis and X-axis scaling varies)
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Ageing Int (2016) 41:89–98
homes mainly appear to pursue the strategy of cost leadership described by M. Porter
(1980) and accept the quality concessions involved.
Study results from Germany confirm findings described in the international literature
which also identified a lower level of quality in for-profit nursing homes (Comondore
et al. 2009, Harrington et al. 2012, Harrington et al. 2015). Also confirmed are results
from a German study which found a correlation between prices charged by nursing
homes and the quality of services provided when examining a smaller sample size of
nursing homes (Mennicken 2013). A new finding from the present study is that quality
differences between German nursing homes exist independent of the price. In the lower
price bracket in particular, the average quality of for-profit nursing homes was found to
be considerably below the quality in non-profit nursing homes of the same segment,
whereas almost no differences between nursing homes were found in the upmost price
segment in relation to profit orientation.
An analysis of the reported interaction between prices charged by nursing homes
and their profit orientation suggests the following interpretation: specifically in the case
of for-profit homes, it is worth selecting a nursing home from a higher price category to
hope that the level of quality will be comparable to the care in non-profit homes. In the
case of non-profit facilities, however, the price charged plays a minor role only in terms
of quality. The lowest price category has many nursing homes that offer quality of the
highest level.
Limitations Several limitations must be considered in the interpretation of study
results. First, the design of a cross-sectional study does not permit to establish a causal
relation. It is true that the quoted economic theories of Porter (1980) and Hansmann
(1980) suggest the existence of such a relation. But the study design only permits to
ascertain that the average for-profit nursing home in Germany, the same as elsewhere,
offers services of a lower quality compared to non-profit institutions. The question
remains open as to whether profit orientation is responsible for this fact.
An important limitation is inherent in the system of assessing nursing home quality
in Germany. The majority of assessment criteria have a low discriminative potential, so
that almost all nursing homes receive good to very good ratings. Moreover, outcome
quality is hardly ascertained. Because the outcome measures did not show differences
in facilities, perhaps the outcome measures should be reexamined for reliability and
validity to determine whether they can distinguish quality among facilities. These
points of criticism have been raised in Germany for years (Hasseler et al. 2010). But
a partial revision of the catalogue of criteria has not included a comprehensive reform
of assessment procedures which was repeatedly postponed by health politicians in the
past. Pending this revision, researchers depend on the data available. Thanks to the fact
that a full assessment of all nursing homes and an unbiased large-scale sample was
available for analysis, it was nevertheless possible to statistically secure quality differences between nursing homes associated with profit orientation.
Another limiting aspect was the impossibility to consider the distribution of nursing
requirements among residents of each home in the analysis since no pertinent data were
available. All nursing homes were therefore assumed to have an individual distribution
of care levels corresponding to the national average, i.e., approximately 40 % of
residents assigned to care levels one and two, and 20 % to care level three. It is unlikely
that this distribution differs between for-profit and non-profit homes in Germany in such
Ageing Int (2016) 41:89–98
97
a way that for-profit nursing homes have more residents in need of intensive nursing
care. This is why it may be assumed that differing compositions of residents in terms of
care levels do not explain quality differences in relation to profit orientation.
A methodological limitation is the fact that requirements for the multivariate
variance analysis employed in the study were not met. On the one hand, there was
no multivariate normal distribution; on the other, it was unclear whether the variancecovariance matrices were sufficiently homogeneous. It may be stated that there was a
high robustness in terms of the alpha error in view of the large sample available.
Moreover, additional non-parametric tests yielded the same results so that the
MANOVA results may be interpreted in the presented form.
Conclusions
For-profit nursing homes in Germany, as shown in other countries, offer a lower level of
quality compared to non-profit homes. The price charged by nursing facilities is related
to quality: higher quality can be expected for higher prices, which applies mainly to forprofit facilities. When selecting a nursing home it is therefore advisable to consider the
profit orientation of the institution. German legislation should require that statutory
public quality reports contain details on the profit orientation of nursing homes, which is
reported on the U.S. government’s nursing home quality report card (CMS 2015).
Acknowledgments We thank the nursing division of the national sickness fund association AOK for the
provision of data, and Mrs. Christina Wagner for support in translating the manuscript.
Compliance with ethical standards
Conflict of interest
There are no competing interests to declare in relation to this manuscript.
Informed Consent The study did not require ethics committee approval since no personal data were
analysed and the assessment of nursing homes was anonymous.
Ethical Treatment of Experimental Subjects (Animal and Human) This article does not contain any
studies with human or animal subjects performed by any of the authors.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were made.
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Max Geraedts MD, MPH, is Professor and Chair of the Institute for Health Systems Research at the School of
Medicine, Faculty of Health, Witten/Herdecke University, Germany.
Charlene Harrington RN, PhD, FAAN, is a Professor emerita of sociology and nursing in the Department of
Social and Behavioral Sciences in the School of Nursing at the University of California, San Francisco.
Daniel Schumacher MA, was at the time of the study a student of business administration at the Faculty of
Management and Economics of Witten/Herdecke University, Germany.
Rike Kraska Dipl. Stat., is a research associate and PhD candidate at the Institute for Health Systems
Research at the School of Medicine, Faculty of Health, Witten/Herdecke University, Germany.